support services in the hospital and the community were used. The desire to take on new cancer patients was lacking, yet an interest in continuing medical.
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Urban family physicians and SUMMARY Members in the Department of Family Medicine of a university teaching hospital were surveyed to find out their involvement in caring for cancer patients. Respondents indicated that many cancer patients were followed, but few cancer support services in the hospital and the community were used. The desire to take on new cancer patients was lacking, yet an interest in continuing medical education existed. Feedback from the department will help guide our Education Committee to develop continuing medical education programs for family physicians caring for cancer patients.
RESUME On a procede a une enquete aupres des membres du departement de medecine familiale d'un centre hospitalier universitaire d'enseignement afin de preciser leur implication dans les soins aupres des cancereux. Les repondants ont indique qu'ils suivaient de nombreux cancereux mais qu'ils faisaient un usage restreint des services de soutien aux cancereux disponibles a l'hopital et dons la communaute. Ils ont exprime leur peu d'enthousiasme a prendre en charge de nouveaux cancereux mais ils ont manifeste un interet en formation medicale continue. Les commentaires du departement guideront notre comite d'education a developper des programmes d'education medicale continue destines aux
medecins de famille impliques dans les soins aux cancereux. Cm Fakn Mysm 1994;40:47-50.
the care of cancer patients MICHAEL
DWVORKIND,
MD, CCFP
PESACH SHVARTZMAN,
MID
PERRY SJ. ADLER, MA
ELIANE D. FRANCO, MD, MPH
tions of patients, family physicians, and potential to play a key role members of specialist oncology teams. 13 in the care of cancer A descriptive study done in London, patients. The rich, long- Ont, found that about 30% of cancer term relationship with the patients die at home, mostly under the patient that continuous, comprehensive care of family physicians.4 This study idencare might foster can reduce the threat tified a need for better communication and anxiety that the diagnosis of cancer between oncology staff and the referring often brings. 1,2 family physician.4 Another study' found Family physicians are not, however, ful- that only 60% of cancer patients thought filling this role at present. Apart from the their family doctors were aware of their early detection, casefinding, and screening current problems. Similar observations for cancer, family physicians in urban areas have been reported from the United States play a decreasing role in the medical care of and Great Britain.2'3'5 oncologic patients, including the palliative But what are the perceptions of urban care phase. This process ofabandonment is family physicians? Are family physicians complex and is influenced by the percep- willing to take on the task of continuous care of cancer patients? Do they feel Dr Dworkind is an Associate Professor in the knowledgeable enough to meet the chalDepartment of Family Medicine at McGill University lenge? How do they want to prepare and is Associate Director ofMedical Services at the themselves to do so? Information of this Herzl Family Practice Centre of The Sir Mortimer B. kind would be important in planning Davis Jewish General Hospital in Montreal. oncologic and palliative care services and Dr Shvartzman is Chairman of the Department continuing medical education (CME). of Family Medicine, Center of Health Sciences at The purpose of this pilot study was to Ben-Gurion University of the Negev in Beer-Sheva, assess interest on the part of urban, Israel. Mr Adler is a Clinical Psychologist, community-based physicians in our Department of Family Medicine in caring Lecturer, and Research Consultant at the Herzl for cancer patients, as well as their use of Family Practice Centre. Dr Franco is a Research Associate in the Department ofFamily Medicine at community resources and their perceived McGill University. needs for CME. AMILY PHYSICIANS HAVE THE
Canadian Family Physician VOL 40: J7anuagr 1994
47
METHODS Population At the time of the questionnaire, the Department of Family Medicine comprised 106 physicians based in the community and at the Herzl Family Practice Centre of the Sir Mortimer B. Davis
Table 1. Number of cancer and palliative care patients seen in the past month: Not all respondents answered all questions. DISTRIBUTION OF FAMILY PHYSICIANS NO. OF PATIENTS FOLLOWED
%
TOTAL
CANCER PATIENTS ..................................................................................................................................................
None
27.9
19
methods for CME. They were also asked whether they were interested in accepting new cancer patients. A six-point Likert scale was used to measure use ofcommunity oncologic resources and interest in CME topics. (Zero represented no use at all of services or no interest at all in CME topics and 5 represented a great use of services or an extreme interest in a CME topic.) Analysis The use of community resources (use score) and the interest in CME topics (interest score) were derived by calculating the means and standard deviations of all the respondents' responses. The Epi Info statistics calculation package, Version 5.00, was used.
..................................................................................................................................................
14.7
1
10
..................................................................................................................................................
2
16.2
4-5 6-10 >10
TOTAL
PALLIATIVE CARE PATIENTS None
12
.................................................................................................................................................
1 .........................................................:
2
..................................................................................................................................................
3-5
TOTAL
I
48
RESULTS
The response rate to the mailed questionnaire was 68.8%. Data were available to compare the respondents (73 doctors) to 7.4 5 the nonrespondents (33 doctors). There 7 10.3 were no significant differences between the two groups in sex, age, university, or 5.8 4 year of graduation or certification. Table I shows the number of cancer 100.0 68 patients the respondents report having seen in the month preceding the study. The family physicians followed a mean of 3.2 such patients (SD 4.4; range = 0 to 20); 56.0 28 of these, a mean of 0.8 (SD 1.3) needed 26.0 13 palliative care. Almost half (48.5%) of the respondents followed one to three cancer 8.0 4 patients; 27.9% followed none. Table 2 shows the use of oncologic 10.0 5 resources by family physicians taking care of cancer patients. No association was 100.0 50 found between the number of patients folJewish General Hospital (SMBD-JGH), a lowed and the resource use score. McGill University teaching hospital. Table 3 shows physicians' interest in CME on five suggested cancer-related Questionnaire topics, and Table 4 shows their preferred An anonymous questionnaire was mailed teaching methods. No association was to all 106 physicians. Using Dillman's found between the number of patients a methodology, we sent three reminders.6 family physician followed and the topics of The questionnaire consisted of seven ques- interest. tions. Family physicians were asked about Only 13.4% of respondents (nine) were the number of cancer and palliative care interested in referrals of more cancer patients seen in their practices during the patients; 65.7% (44) were unwilling to previous month, their use of community receive any new referrals. No correlation cancer resources, their interest in proposed was found between number of patients foltopics for CME, and their preferred lowed and interest in more referrals. 17.6
3
11
Canadian Family Physician VOL 40: Januagy 1994
DISCUSSION The therapeutic oncology team is composed of nurses, a medical and a surgical oncologist, radiotherapists, and other surgical subspecialists, whose focus on cancer treatment does not necessarily include interaction with primary care physicians. In fact, the intensity of the oncology team's involvement seems to lead to the exclusion of family physicians. Conversely, primary care physicians might feel intimidated by the high-tech investigations. They might believe they have too little knowledge of new advances in the treatment of cancer and might fear the emotional fall out of a life-threatening illness and possibly death of the patient. These factors, along with the time and energy requirements of busy office practice, could preclude active involvement.7'" In a study done by McWhinney and colleagues' on 493 cancer patients who said that they had a family doctor, the family doctor had, according to the patients, been involved in the diagnosis of 282 (57.2%), the treatment of 132 (26.8%), and the follow up of 214 (43.4%). Our respondents reported variable involvement. A survey of family physicians at the London Regional Cancer Clinic in Ontario found that two thirds of respondents felt a need for additional supportive care from other health professionals.4 Our urban family physician group did not use either hospital or community oncology support services much - possibly because they were unaware of or dissatisfied with such services or found them unavailable, or possibly because their training did not emphasize the multidisciplinary approach. It is often difficult for family physicians to become reinvolved after a long separation. The patient and family who perceive that their family physician has abandoned them have often developed an emotional bond to the cancer centre and might have also lost confidence in their doctor's ability to help.7'8" 0"1 Yet the family physicians in our study showed interest in improving relevant knowledge, attitudes, and skills, especially in symptom control and pain management: areas in which family physicians can play an important assessment and therapeutic role.2"l2 The most
attractive form of CME was case presentations, followed by lectures and seminars. The challenge for medical educators is to develop a case-centred CME program that focuses on the educational needs identified by family physicians. 13 Although most of our respondents were following a small number of cancer patients, very few were interested in new referrals. (Four mentioned retirement plans as a reason.) However, reluctance to accept new referrals does not necessarily mean that family physicians would not be
Table 2. Resources used by family physicians in caring for cancer patients: Not all respondents answered all questions. TYPE OF RESOURCE
MEAN USE (±SD)*
TOTAL
Hope and Cope volunteer servicest
2.0 (±1.6)
54
CLSC Home Care'
1.8 (±1.7)
51
Oncology nurses§
1.7 (±1.9)
50
Social services
1.6 (±1.6)
48
Palliative care
1.2 (±1.5)
47
Supportive Care Team1'
1.0 (±1.5)
45
Chaplain services
0.6 (± 1.2)
46
*Likert scale: 0 - no use at all; 5 - very frequent use. Volunteer support service.
+Quebec Community Health Centre. §Oncology ambulatory clinic staff
LAIMultidisciplinary hospital-based consultation team. Table 3. Physicians' interest in CME topics: Not all respondents answered all questions. CONTINUING MEDICAL EDUCATION TOPIC
Symptom control ................................I .......................
MEAN INTEREST (±SD)*
TOTAL
3.5 (±1.5)
67
...................................................................................
Rehabilitation
3.1 (±1.6)
64
......................................................................................................I...........................................
Chemotherapy/radiotherapy
2.8 (±1.5)
64
Family consultation
3.2 (±1.6)
64
...I..............................................................................................................................................
Grief counseling
2.9 (±1.7)
54
*Likert scale: 0 - no interest at all; 5 - extreme interest.
Canadian Fami}y Physician VOL 40: ]anua9' 1994
49
willing to follow up their own patients should they develop cancer. The care of the patient with cancer provides an example of the gap that often occurs between primary care providers, secondary care providers, and patients: a gap all three groups have helped to create.
Table 4. Preferred CME methods TEACHING METHOD
PROPORTION INTERESTED (%)
TOTAl*
70.5
61
Case presentations
.................................................................................................................................................
Lectures
60.0
...........................I.................................I.............I....................
60 .................................................
Seminars
57.9
57
Small group discussions
48.2
54
*Number of respondents who answered the question This separation has several possible harmful consequences. Dying patients who prefer to be at home might have no physician to attend them. Cancer clinics might be overloaded with patients who could be treated by family physicians, especially in the palliative phase. Patients and families might incur needless cost and inconvenience traveling to clinics when home care would be more appropriate.14 Finally, patients and families might miss the continuing support of a family physician when they have to make informed medical and ethical decisions on difficult questions of investigation and treatment. 15'16 Perhaps family physicians will become more interested and involved in oncologic care if they can gain more knowledge and skills, better links with community resources, and enhanced communication with the oncologic teams. This study might not be representative of family physicians' perceptions in urban centres in other parts of North America. Thus, the generalizability of the results might be limited.6 However, as a pilot study, it could offer some insights into the role of urban family physicians in the care of cancer patients. Further research on the role of family physicians in all stages of oncologic care is important both to patients and to the U discipline of family medicine.
Acknowledgment We thank Drs Michael Klein, Yvonne Steinert, and Ian Shrierfor their help andguidance in reviewing the manuscript and Ms 3. Solin for her technical assistance. 50
Canadian Family Physician VOL 40: january 1994
Requests for reprints to: Dr Michael Dworkind, Herzl Family Practice Centre, Sir Mortimer B. Davis Jewish General Hospital, 3755 Chemin de la Cote St Catherine, Montreal, QC H3T 1E2
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Soc Sci MVIed 1990;30(11):1241-6. 9. Seravalli EP. I'he dying patient. The physician on the fear of death. NEnglJ Med 1988;319(26): 1728-30. 10. Chafer S. What you should know about palliative care. Geriatrics 1990 June/July):31-7. 11. DavisJM. Hope or hopelessness? Postgrad A/fed 1990;87(8):22-3,26. 12. Latimer E. Caring for seriously ill and dying patients: the philosophy and ethics. Can AMed Assoc J 199 1; 144(7):859-64. 13. Steinert Y, Golden M, Klein M. Teaching the behavioral sciences in family medicine. Can Fam Physician 1981;27:807-1 1. 14. Dawson HR. Palliative care in the home for the family physician: a teaching hospital model. Can Fam Physician 1987;33:2771-7. 15. LynnJ. Choices of curative and palliative care for cancer patients. CA Cancer] Clin 1986;36(2): 100-4. 16. O'ConnorJA, Burge Fl, King B, EpsteinJ. Does care exclude cure in palliative care?]7 Palliat
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